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Review
. 2021 Dec 27;14(Suppl 4):i98-i113.
doi: 10.1093/ckj/sfab193. eCollection 2021 Dec.

Informed decision-making in delivery of dialysis: combining clinical outcomes with sustainability

Affiliations
Review

Informed decision-making in delivery of dialysis: combining clinical outcomes with sustainability

Christian Apel et al. Clin Kidney J. .

Abstract

As the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.

Keywords: haemodialysis; informed-decision making; sustainability; value-based healthcare.

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Figures

FIGURE 1:
FIGURE 1:
Transformation to a high-value care delivery system has physicians and provider organizations taking the lead, but each of the other stakeholders—including the patient—has a role to play in improving the value of care and hastening transformation by aligning incentives across stakeholders for mutual benefit. GP, general practitioner; IQWIG, Institute for Quality and Efficiency in Health Care; HAS, Haute Autorité de Santé (or French National Authority for Health).
FIGURE 2:
FIGURE 2:
Delivery of personalized medicine and VBHC necessitates evidence-informed decision-making, not just by physicians, but also by policymakers and stakeholders. Successful implementation of VBHC (outcomes divided by costs) is achieved by assessing evidence and data for clinical outcomes and sustainability decision-making.
FIGURE 3:
FIGURE 3:
The cost-effectiveness plane, showing that ‘willingness to pay’ is one of the most important payer tools to assess the value (cost effectiveness) of an intervention. The fundamental premise of VBHC is that if value improves, patients, payers, providers and suppliers can all benefit while the economic sustainability of the healthcare system increases.
FIGURE 4:
FIGURE 4:
The cost-effectiveness plane, showing the payers ‘willingness to pay’ for cHHD (3×/week, 4 h) and iHHD (e.g. 8 h thrice weekly/day or nocturnal and 5 × 3 h) compared with conventional (3×/week, 4 h) iCHD.
FIGURE 5:
FIGURE 5:
Clinical and economic value of iHHD (relative to conventional iCHD). Such analyses are the basis of VBHC and are carried out by health technology assessment agencies to guide the payability of therapies based on the clinical benefits obtained based on evidence.
FIGURE 6:
FIGURE 6:
Clinical and economic value of HV-HDF relative to conventional high-flux HD. ESA, erythropoiesis-stimulating agent.

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